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HomeMy WebLinkAbout020-1024-80-120 -0 0 c ~ 3 o I O ~ d 4 tl C ` C ~ rn I r O 7 0 9 N w /9 ~ x z E -5 C > ay? N y 0 0 d y Tw 0:9 y rN axi m w ~j--D I L j m c w a c o vQ~ o o W w= (D 10 v F U Q U) QO N C C (n N N O 0-0.9-0 N Y O~ C to W N E fO L p C f0 0 w N O N L N M ~ C C w o -0 0) m 2 _0 c- c y a~i c m Uo Q a o O m u N~c 0 3 I v ~I m I 3 z y z = o v 03 Z %I € m c c j o z z j c N c o z E O N Cl) m c m N N w Z H Z z N 0 c N N !0 E Y 12 m m CL a co 2 a G O a .0 c r m rr o Z m > a z o 3 $ = 0 0 0 0 z • N n. n. a y a. _ (~i ~ p y ~ ~ c0 I 1~ fA J U c OOi OOi aw' O r Xa) = ^1 7 O o m E c m 'n m m a cn m ~ I 8~ U) O o m wi c C-4 N 0 E ti 0 rn y o a 0) o ao 0 o E a c~ r' N O N of {C 0 E C 7 M 40 1 CO V) I. O N 0 0 LO 'y y d N C f0 f0 •O O A S N O z C~ V V~ I € a I • ~ a m li d d v ~1 A c°~ IL v~ c~ STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER -ZA-A'( /G C Ek, /~e C K V ~ A 1`N ADDRESS 1 sC-6 C A D V u-) / SUBDIVISION / CSM# -7 ~ LOT # 3 SECTION I T '1 N-R q1 W Town of T DSc" ST. CROIX COUNTY, WISCONSIN ~2jKk LA PLAN VIEW ~r3t 9149W E 00 FEET OF SYSTE LL- ~dxsD~n T .T ~S INDICATE NORTH ARROW Provide setback and elevation information eon reverse o f this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: Tmp on F `P 67 n VO ALTERNATE BM: Ie< '-t) ;,i CSEPTIC ZK7~)PUMP CHAMBER / HOLDING TANK INFORMATION Ma nufacturer:~_~ Liquid Capacity: Gou, ~ r Setback from: Well ( House 17 Other Sw 6cfaof at NJuS~ Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: S Length (00 Number of trenches Z_- 64 Distance & Direction to nearest prop. line: (P7 it) '5ooTI Setback from: well: /I L House Other ELEVATIONS NS Building Sewer ` ST Inlet. (P,40 ST outlet PC inlet PC bottom Pump Off Header/Manifold-...I, Bottom of system 9-7 Existing Grade Final grade S-,) i DATE OF INSTALLATIO~ON'':/~ PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt WiscomimDepartmentofIndustry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Divisio on GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI . MILLER, SAM X CST BM Elev.: Insp. BM Elev.: BM Description: ~ Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV_ Septic r~ Benchmark Dosing Aeration Bldg. Sewer In9 St/ FJeInlet G, 98 ' TANK SETBACK INFORMATION St / lidoutlet 97 '!~7' Vent TANK TO P/ L WELL BLDG. A irIto ntake ROAD Dt Inlet NA Dt Bottom 1714 Septic y50' >550' /7 Dosin NA Header/+4m, 7 rr,-70' 351 7 ~'oo Aeratio A Dist. Pipe F. 87 olding Bot. System /D. 60, PUMP/ SIPHON INFORMATION Final Grade S ~n Ma Demand ° r Cdr 3 , /o 77- 71d) Model Number GPM TDH Friction System TDH Ft Fo emain Length Dia. Fi Dist. To Well I F SOIL ABSORPTION SYSTEM BED/TRENCH Width Length r No. Of Trenches PIT No. Of Pits In ia. Liquid epth DIMENSIONS S DIMEN 1 -11 SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEAC INFORMATION Type O ¢.N- f MBER Moe Number: System: ire (pa - I' `OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) i x Ho x Hole S Vent To Air Intake Length L Dia. Length S7 / Dia. --L Spacing SOIL COVER x Pressure Systems Only xx Mound O -Grade Systems On Depth Over Depth Over xx Depth ,6f xx Seeded/ Sodded xx Mulched Trench Center PA*1-Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson-15.29.19W, NE, E, Lot 3, Scott Road e (>t r ,7 r ~ ~ Eel c ` S . c c~ Cc net t 0/ CJ , . -7, C-2 :S 117-t 11 Plan'r vision required? ❑ Yes EKO Use other side for additional information. SBD-6710(R 05/91) Date Inspector's Signature Cert.No - L ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION BSafeureaty u anofd B uiildiinng Water gs ter Systems tems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. 5-~- C ~'pl See reverse side for instructions for completing this application State Sanitary e it Nunn I The information you provide may be used by other government agency programs ❑ Check if revon previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location / G L EA, *41 14/yE 1/4, S t~S T Z q . N, R l17 E (o~ Property Owner's Mailing Address Lot Number Block Number 426 P- f Z 3 City, State Zip Code Phone Number Subdivision Narf)e or CSM Number H a 0 Z 0 N W r s/0/ &8"w Z74, 1!S AA y~-7 y 7- II. TYPE F B ILDING: (check one) ❑ State Owned !tIy Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 0] Z Towan OF HL)()J ON 3~o7T RZs4 0 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo © Z D - Id z-- $o Z© 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel / Motel 9' ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. Cg New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank 12, Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Q Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation S G (.O C) 9 7~ Feet '771 64 Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete st tined Steel plastic grass App. Tanks Tanks Septic Tank or Holding Tank X /000 1 4 L4-) ct,_ q D ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (N Stamps MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, ip Code): !0 Co 2F- 114- G f} ~!E r✓v o N t c.~ / 5- IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing gent Si ature (N amp XApproved Surcharge Fee) ❑ Owner Given Initial Adverse Determination t/ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: i SBD-6398 (R. 05/94) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained- The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-381 S. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required b the county; E) soil test data n 11 y y; , ) o a 5 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. 94257 LoT~ 3 SALE I~y~=/o' TeAl E I. lac ~cA /;?1' S-t~3Soo 7 7 s c o'" ~4f~I~ ~ LoT 3 C S M. or /ov " DRIVE WAY vV F- LL - - No~ SE dip XSo LO rS• y fI LTfr2- I I 1 uo t y r a, N1. To jPf 6T ScJ lo~N~~ Fl. _ /va. oo ' I C L /\r1 = C v T c 1-1 Ep L) ~-O ~4 D Z J ?r ~i N o Ttl I 4 M -u , I m i b zi C~6 Oll t~ O r I o I I _0 ! O :U- I M J w i N_ I A ~ N Z I -0 1 W I FF \l\\ I m o, 0 J J g O O O C ~ , rn LA Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page -L of Z Labor and Human Relations DiYrsion of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ~5T 69(3) X not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION 'SA R, M i L LF-P, GOVT. LOT NE 1/4 lt[ 1/4,S j S T 29 N,R E (w) W PROPERTY OWNEIT:S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLA E OWN NEAREST ROAD ( ) SC)1~ mccu . GNEOrJ (~J New Construction Use[ ] Residential / Number of bedrooms Mf, [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S = Suitable for system QQNENT L M UND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL T HOLDING T MI U= Unsuitable fors stem ((11~~ S ❑ U N S ❑ U K Do S ❑ U S❑ U ®S O U ❑ S QU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmnch pp C)-9 bi 3 l L i m t;L< nT r CS 4 S 9, 9 Z4 I 7,5/P, 4 4 - L 6 Ai r C S VIA 15S_ Ground & 24 -An / YR 4 - S ®YR r- nt 63 lev. LULft -122 16YQ 414 Depth to limiting factor } Remarks: Boring # 6,71i Wr ' LjA5 /IN fl&i l A'_ i r&A AI 6 ~V) 1,3 Ground P W -M 7 t0 wK1cq( S 14 L elev. "T6 ft Ike L Depth to limiting factor Remarks: CST Name:-Please Print ~le VA_ y Q i4Ntoti Phone: Address: P0, ZJ A Signature: Date: 9/-? Q ! CST Number:: 44 L r v. o~ru I A .IZ ~ 1 0 ` 169' ~ ' 3 B 6 8320' A 1 Nlpi E o AN 44&ITjom4t. N4 WAS TAILF NJ g~ ~REJISC TNAT hoc- TA KEN X196 Cs~oo34g4 i f " McCus-cNic~j ~Ao Y DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, C DIVISION LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON, WI 7969 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/ OT NO.: BLK- NO.: SUBDIVISION NAME: N N ir- /S /T-z9 N/Rn E ( ) W COUNTY: MAILING ADDRESS: >r--':r C,~G ~~RC_a,2-~N ~q0 /`~IcCuTC~~Uz, Ku NUGr~ti ._f~, USE DATES OBSERVATIONS MADE 7NDRMS.: COMMER IAL DESCRIPTION: r ROFILE DESCRIPTIONS: JP~RCOLATION TESTS' XResidence XNew ❑Replace < Ly 2 ~ 7TO U:Y ) RATING: S= Site suitable for system U= Site unsuitable for system A~ ll T CONVENTIONAL: MOUND: IN-GROUND-PRESSURE SYSTEM-IN-FILLHOLDINGr~TAANI: RECOM ENDED SYSTEM:(optio al) -1 S ❑U l~'S ❑U S ❑U 12 S ❑U ❑ S I~JU pNJC ~fT) n~+~~~t•.< It Percolation Tests are NOT required DESIG RATE: I If an L y portion of the tested area is in the , I under s. ILHR 83.0915)(b), indicate: Z ~~S Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHIM ELEVATION OBSERVED EST, I HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B 9 BLCTS ~BRnI C /FS ep,j /ti1S t R,. =c-+Ct u B- 2 OC!, t 01 > /&60 -e , -7 4 "@?, c.` G1'2 B&,(,7 9q .4~ f~ c~rlt~ > -~7 „g: c~t':, ua, jry .•g~N M 7v' B- 9 AZ 4s,1-7 / Pcc -i~ 9 "ISR, L z -z R,, r17-5 B- < 9.33 97.77 > 9.31 B- ~Ec PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DRO I WATER L V L-IN HES RATE MINUTES NUMBER 4WfidrS AFTER SWELLING INTERVAL-MIN. PERIOD 1 P RI D 2 P R PER INCH P- I S10 c /06,110 3 Z y `Z > Z P- Z 3,30 >s 9,7,g 3 >Z >`4 >Z <3 P- x.50 p+. >2 Z P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION. T 4b -A- , ,or v $ 3 e~,~cu~,a K 1 Ro>J PIPE A r St.,/ ,ur_ o U; ) I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON NAP-VI Sr;,-.._s:,~..1k`;jr,c l n,c J /970 ADDRESS: CERTIFICATI0 NUMBER: PHONE NUMBER (optional) 46-7 flu J~,:s6r, V/, C, I C CST I TUBE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester, )ILHR.SBD-6395 (R. 10/83) - OVER - f 4629'7'7 CERTIFIED SURVEY MAP Located in the NE 1 /4 of the NE 1 /4 of Section 15, T29N, R 19W , Town of Hudson, St. Croix County, Wisconsin. Owned by: Greg Corcoran East line of the NE1/4 of Sect:ioh1 I5. 690 McCutcheon Rd. Hudson, Wi. 54016 NE Corner S 1°02'29"W l/4 Corner Section 15 3 Sectio T29N, R 19W 1311.6 s' io 1311.69' t` I V 10 UNPLATTED LANDS S S 00'57'21"W 56.18' Z z M i W1 _1 ILEA 628.27' I 1-1 .41 z 1 ~ ~ al 1 ~ OCT 4 51990► LO _T I t- Zl acot4NELL rn ~I N oil JI►M t o Deeds m 171,.067 Square feet (3.921 acres) r Ql- - - _ StCrObcOo"W~ / N Including right-of-way N~ ~01 ~p _BAKKE ti 163,641 Square feet (3.761 acres) I 1 'o ROAD Excluding right-of-way - • - ( 2 8.20' North line of h S 1 2 of the NE 1 4 South line of the NE I /4 of the NE 1 /4 of Section 15. N00022'5d'iE ( I of the NE 1 /4 of n 656.39 al W JI 171, 136 S. F. (3.929 Ac) Inc. ROW Shed SIN (0 rIN~ W rn z 11 LU ~ -I 163, 835 S. F. N rn a > 0, °I (3.761 Ac) w tea) I M UQ WI s Exc. ROW House -lct 3 ~1 101 Q I l_ al 628.17' in- "t J j~ N 00'11'30"W 656.67' 3) hlol I N L07 3 _01 ~ 264, 343 Square feet (6.069 Acres) N Iz (a WI I 4 o Including right-of-way I zz 0 228,981 Square feet (5.257 Acres): I F - N 12' Excluding right-of-way 0 ml. I M N 0° 1 1' 30"W 152.92' ~I n ZI S' ~7107 m Oil of ~I ~I ~ w Zl w. c 1-il °I s N Z N I ( N a~ M a- West line of the NE 1 /4 of I vl zl Lo N C" the NE I /4 a' ~1 w CO f V 01 w 4 C\ Z_ S 00' i 1_30"E 474.28' w 8 SCOTT ROAD a►~-i ' Z - w c0 J N 00'4158"E 503. i•5'..._ ZI Q UNPLATTED LANDS_ I 0 LEGEND 16 6'1 Section Corner monument 0 1 "X24" Iron pipe weighing 1.68 lbs per lin. ft. set. • 1" round iron pipe found: Bearings referenced to the East line _ FENCELINE - of the NE1/4, of Section 15, assumed (R) Previously recorded information. S 1°02'29"W -*@ This instrument drafted by 489-1648 VOLUME 8 PAGE 2279 1 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER S /4 /y! MAILING ADDRESSX Z 9 Z f PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CTTY/STATE 11y D S O N Ga l SAO/4 PROPERTY LOCATION Nr 1/4, N E 1/4, Section 5 T N-R TOWN OFU S ON ST. CROIX COUNTY, WI SUBDIVISION G fo Y! LOT NUMBER 3 CERTIFIED SURVEY MAP a 9 i VOLUME e , PAGE: ?2 7 9 , LOT NUMBER _ Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. .a r SIGNED: F, DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, Wl 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office' with the appropriate deed recording. Owner of property f;,4 ,~Z Life Location of property-1/4 /f-F 1/4, Section/Jr-l ,T9 7 N-R W Township UDSoM Mailing address f~v~s~ N w i .~yo i~ Address of site 7-27 <0 7?` _0A1D Subdivision name ( M L,Llo L 9 7 -7 Lot no. _3 Other homes on property? Yes X No Previous owner of property aeE ~o,e y f, ~p,e O /y Total size of property o(P y 6¢L Total size of parcel el 14V 4L Date parcel was created 7-3/- y0 Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? Z Yes No Volume 037 and Page Number ~ ~ as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. S~ 2 ~ SS Sri nature of Applicant Co-Applicant / (_q 5' Date of Signature Date of Signature State Bar t,' V. isconsin Fornt 2 I•4C ' 5331Ja WARRANTY DEED . DOCUMENT NO. l137Far 4liJ t - Gregory J. Corcoran and Virginia K. 1t~ 2 9 1950 Corcoran, as tenants in common, - AUu - ~ 11:30 A. s - conveys and warrants to _Sam E. filler,-. _ THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following dscribed real estate in . St. Croix ' County, State of Wisconsin: .~r (Parcel Identification Number) 1 Part of NE 1/4 rf NE 1/4 of Section 15-7Z- -R19W described as follows: Lot 1 of Certified Survey Map recorded i= volume 8 of Certified Survey Maps, Page 2275; as Document Number 4629:7, and Part of NE 1/4 of NE 1/4 of Section 15-=9%-Rl9W described as follows: Lot 3 of Certified Survey Map recorded i^ volume 8 of Certified Survey Maps, Page 2279, as Document Number 462977- St. Croix County, Wisconsin. is not This homestead property. (is) (is not) Exception to warranties: Subject to easements, reservations and restrictions of record. Dated this 28 - - -day of - AySliS.t-- • 19. 9 5 . n - (SEAL) 4 - (SEAL) " VEG CORCORAN (SEAL) (SEAL) . CORCORAN AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St. Croix _ County. authenticated this day of • 19-- Personally came before me this 28 day of August • 19 95 the above named Gregory J. Corcoran and Virginia K. - Corcoran, TITLE: MEMBER STATE BAR OF WISCONSIN (If not. authorized by §706.06, Wis. Stats.) to k wn to be~~~a the perso' s who executed the foregi' g instrnd~ledge the same. THIS INS 1 RUMEN? WAS DRAFTED BY r _ STEPHEN J. rctr-ql Brenda Poulin - - Hudson, Wisconsin Notary Put;"c - - _ state af_yVlscpnin %otar Public St-Croix - -~ta of ~n. NOV. - Y - - Cotmty. Wis. (Signatures may be authenticated or aAno i are not My commission is permanent. (If not. state expiration date: necessary.) - 11/24 1996 ) 'Name, of per,un%,igning in am capaciti, •h-W he aped n printed helnw tlir .uyetve. w'ARRANTI' DEED STAFE R-%R CW c _O%S[N Wisconsin Legal Blank Co . Inc FORM ~_-NR, h5lwaukee. Wes i